Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Saturday, August 11, 2007

Got called to a CODE BLUE on the floor the other day. I still run to them and as I barreled around the final hallway the nurse standing in the patient's door gave me the "wave-off" sign so I slowed down. In a whisper I asked her what was going on and she told me that the husband of the patient had decided against resuscitation for his dying wife. I poked my head quietly in the room and saw him at his wife's bedside, crying, and patting her on the head and telling her he loved her.

The patient had widely metastatic cancer and, as I turned to walk away I found myself thinking about the courage it takes to actually comply with previously discussed wishes when death arrives. This gentleman made the right decision to let her go. One day I will have to do this for one of my family members or one of them will have to do it for me. I pray for the same kind of courage when the time comes.

"do everything you can" is most definitely a form of cowardice...and especially selfishness. If it's mom's time to go, and mom wants to go (or made it clear that when this time came, she would want to go), then to direct the physicians to do otherwise is fear...fear of your loss, fear of being 'blamed' or of blaming yourself, and most of all, a decision not to honor HER wishes, but to honor YOURS

When it came time for me, in a similar circumstance---in my thoughts, I chickened out and wanted a full Code, even though it was my against father's last wish. However, his DNR wish was carried out by my brave mother. But I must admit that if the choice had been mine to make---I would have gone against his wish. And I admit that this sounds terrible and selfish. I had become irrational at that moment....

agree about the trauma scenario...that's a different thing altogether. And I don't mean to offend when calling the decision "cowardly"...I mean that more as a description of the emotion (fear, as well as love) than of the person having the emotion

911 doc, you have a thing or two to be proud of and I'd like to point one or two of those things out if you don't mind.

When my mother was close to death, she gathered her children and her grandchildren in a hospital room and asked if it was "alright" for her to die. It was the most difficult question I had ever been asked, and the most difficult answer I have ever given. With tears in our eyes, our answer was obvious. "Yes Mom, it's okay. We'll miss you but it's okay to let go." She asked us to take her home to die.

Dr. 911, here is where you come in. Unlike my mother's doctor, who was unsure that it was the proper thing to do, you allowed this couple to end the time they had together with love, respect, and dignity. I had to fight for 4 hours with my mother's doctor before he conceeded and allowed her to come home with us so she could be with her family as she wanted to do.

You, and maybe others may be wondering if my mother still had a "hope" for a normal and productive life. She did not. She had end stage CHF. Her blood pressure was being maintained by dopamine (which infiltrated and we refused to have re-started), and the doctor wanted to put her on a ventilator to regulate her breathing. She said no.

After a long battle, our mother come home with us. She died as she lived, with her family at her side.

Perhaps doctors think they have failed when their patients die. If they have run the full course, and done the best they could have done for their patient; life eventually comes full circle and death, although we may not like it, is inevitable.

The man in your post who made the "right" decision to allow his wife to finally find peace is no more noble than the doctor who allowed this man to give his wife peace.

some doctors are still uncomfortable about giving advice or making prognostications in end-of-life situations. i believe that we abdicate our professional responsibility by NOT offering our opinions to patient's and families, and even well-considered advice.

many physicians were trained to "present all the information" and then to stand back and let the family and patient decide what to do. this would be the equivalent of me being stranded on a beach in the deep pacific and having a few minutes to talk with an expert sailor about how to navigate by the stars and how to make a seaworthy craft only to have him say, after these few minutes, "okay, it's up to you now." uh, thanks for nothing, i didn't understand a single word you said and now i'm freaking out.

thankfully, i do not believe that the younger generation of doctors, in general, is as uncomfortable in admitting the futility of some of the care we can give as the older generation. on the rare occasion when someone asks me what i would do if i were in there shoes i answer them as follows... "if (the patient) were my mother or father (etc...) i would choose 'X'." then, whatever decision they make, i reassure them that it was the right one and i do as they wish.

I am so glad I got to be with my uncle when he was home with hospice care during his last days battling cancer.

It was surreal in a way because amidst the dying process, there was still laughter and life moving forward yet, so very sad at the same time.

I almost didn't make it up to see him as I had been ill earlier that day but by evening was feeling better and so was able to make the 4 hour trip. I was able to spend a couple of hours with him that night and even though he was hardly able to communicate he did manage to say something humorous and share some deathbed wisdom that I shall never forget. The next day he was not able to communicate, spiked a temp over 104 and I believe they said he was septic.

It must be so difficult as a family member to make these decisions even when you know you are honoring their wishes. Although I have a friend who's mother died a painful death from bone cancer. She said her mother begged her to kill her and she said if she could have run her over with a car she would have felt it was a merciful thing to do.

I dread ever having to decide those things.

I thought if a patient has a DNR that it is the law that it has to be carried out?

good point about 'DNR' orders. certainly we honor them but, as many folks are unaware, "DNR" does not mean "Do Not Treat".

first of all and for a variety of reasons many patient's do not have a "DNR". Secondly, many who do, DO in fact, desire treatment up to a point. For instance, if an end-stage cancer patient comes in with pneumonia, that particular problem may or may not be something that can be temporarily cured with a short course of antibiotics. Then the question for the patient and family gets a bit complicated.

Also, as has already been mentioned, the DNR can be rescinded at any time pretty much by anyone in the room that has any connection to the family. Legally, this is probably not true, but when I am in a rescucitation and any family member says "do everything" i do not have time to argue with them and i do not have time to figure out whether they have the legal right to do it. if they are related by marriage or genes, or even as the patient's 'power of attorney' then i, in fact, will "do everything" as i would rather defend a "wrongful life" suit in court that a wrongful death one.

Thank you. I didn't know this and I worked in ED registration for 20 years and was right in the middle of it. I never heard staff say this. I just assumed since a DNR was do not resuscitate that they wouldn't. I guess that's where the advanced directives come in to play. I used to hand them out and explain them to the inquiring patients and yet I don't have them and neither does my elderly mother. I should approach her with the papers but that is so awkward. I do know better, but...